Safety of same-day discharge for minimally invasive hysterectomy for endometrial cancer

Minimally invasive hysterectomy same-day discharge: systematic review and meta-analysis of predictors

PURPOSE

Same-day discharge (SDD) is increasingly prevalent following minimally invasive hysterectomy (MIH). However, consensus guidelines for selecting SDD eligibility criteria for MIH remain unexplored. This study aims to identify predictive factors for non-SDD following MIH (registered in PROSPERO CRD42022350373).

METHODS

PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. All original studies that involve patients who were discharged on the same day are compared with those who were not (not failure to discharge / not intended to discharge). Categorical and continuous variables were reported as risk ratios with 95% confidence intervals and weighted mean differences with 95% CIs, respectively. Heterogeneity among the included studies was assessed using the I2 statistics. We conducted sensitivity analysis to identify the reason(s) for this heterogeneity.

RESULTS

Ten studies (59,589 patients) were included, with a mean SDD rate of 20.28%. The predictors of overnight observation included factors such as American Society of Anesthesiologists classification (ASA) > II (P = .02; I2 = 92%), increased estimated blood loss (EBL) (P < 0.00001; I2 = 87%), surgeries starting later in the day (P < 0.00, I2 = 15%), and longer operation times (P = .002; I2 = 96%). In sensitivity and subgroup analyses, uterus weight emerged as a potential factor (P < 0.00; I2 = 50%), while the results concerning ASA, uterine weight, and EBL appeared to be homogeneous. However, the operation time remained heterogeneous.

CONCLUSION

These factors could assist surgeons in the decision-making process regarding the performance of SDD subsequent to MIH procedures for patients.

Variables impacting prolonged post-anesthesia care unit length of stay in gynecologic cancer patients in the era of same day minimally invasive hysterectomy

OBJECTIVES

Minimally invasive surgery for treatment of gynecologic malignancies is associated with decreased pain, fewer complications, earlier return to activity, lower cost, and shorter hospital stays. Patients are often discharged the day of surgery, but occasionally stay overnight due to prolonged post-anesthesia care unit (PACU) stays. The objective of this study was to identify risk factors for prolonged PACU length of stay (LOS).

METHODS

This is a single institution retrospective review of patients who underwent minimally invasive hysterectomy for gynecologic cancer from 2019 to 2022 and had a hospital stay <24-h. The primary outcome was PACU LOS. Demographics, pre-operative diagnoses, and surgical characteristics were recorded. After Box-Cox transformation, linear regression was used to determine significant predictors of PACU LOS.

RESULTS

For the 661 patients identified, median PACU LOS was 5.04 h (range 2.16-23.76 h). On univariate analysis, longer PACU LOS was associated with increased age (ρ = 0.106, p = 0.006), non-partnered status [mean difference (MD) = 0.019, p = 0.099], increased alcohol use (MD = 0.018, p = 0.102), increased Charlson Comorbidity Index (CCI) score (ρ = 0.065, p = 0.097), and ASA class ≥3 (MD = 0.033, p = 0.002). Using multivariate linear regression, increased age (R2 = 0.0011, p = 0.043), non-partnered status (R2 = 0.0389, p < 0.001), and ASA class ≥3 (R2 = 0.0250, p = 0.023) were associated with increased PACU LOS.

CONCLUSIONS

Identifying patients at risk for prolonged PACU LOS, including patients who are older, non-partnered, and have an ASA class ≥3, may allow for interventions to improve patient experience, better utilize hospital resources, decrease PACU overcrowding, and limit postoperative admissions and complications. The relationship between non-partnered status and PACU LOS is the most novel relationship identified in this study.

Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

Factors influencing same-day discharge after minimally invasive hysterectomy for malignant and non-malignant gynecological diseases: a systematic review and meta-analysis

Objective

To explore the factors influencing the successful implementation of same-day discharge in patients undergoing minimally invasive hysterectomy for malignant and non-malignant gynecological diseases.

Method

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform, and Clinical Trials.gov from inception to May 23, 2023. We included case-control and cohort studies published in English reporting same-day discharge factors in patients undergoing minimally invasive hysterectomy for malignant and non-malignant gynecological diseases. STATA 16.0 was used for the meta-analysis. Risk factors were assessed using odds ratios (OR) (relative risk (RR)/hazard ratios (HR)) with 95% confidence intervals (CI), and logistic regression determined the same-day discharge rate (%).

Results

We analyzed 29 studies with 218192 patients scheduled for or meeting same-day discharge criteria. The pooled rates were 50% (95% CI 0.46-0.55), and were similar for malignant and non-malignant gynecological diseases (48% and 47%, respectively). In terms of basic characteristics, an increase in age (OR: 1.03; 95% CI: 1.01-1.05), BMI (OR: 1.02; 95% CI: 1.01-1.03), and comorbidities including diabetes and lung disease were risk factors affecting SDD, while previous abdominal surgery history (OR: 1.54; 95% CI: 0.93-2.55) and hypertension (OR: 1.53; 95% CI: 0.80-2.93) appeared not to affect SDD. In terms of surgical characteristics, radical hysterectomy (OR: 3.46; 95% CI: 1.90-6.29), surgery starting after 14:00 (OR: 4.07; 95% CI: 1.36-12.17), longer surgical time (OR: 1.03; 95% CI: 1.01-1.06), intraoperative complications (OR: 4.68; 95% CI: 1.78-12.27), postoperative complications (OR: 3.97; 95% CI: 1.68-9.39), and surgeon preference (OR: 4.47; 95% CI: 2.08-9.60) were identified as risk factors. However, robotic surgery (OR: 0.44; 95% CI: 0.14-1.42) and intraoperative blood loss (OR: 1.16; 95% CI: 0.98-1.38) did not affect same-day discharge.

Conclusions

An increase in age, body mass index, and distance to home; certain comorbidities (e.g., diabetes, lung disease), radical hysterectomy, surgery starting after 14:00, longer surgical time, operative complications, and surgeon preference were risk factors preventing same-day discharge. Same-day discharge rates were similar between malignant and non-malignant gynecological diseases. The surgery start time and body mass index have a greater impact on same-day discharge for malignant diseases than non-malignant diseases.

Analysis of Sociodemographic Factors Affecting Ambulatory Surgical Center Discharge Patterns for Endometrial Cancer Hysterectomies

STUDY OBJECTIVE

Investigate outcomes for patients undergoing minimally invasive hysterectomies (MIHs) performed for endometrial cancer at ambulatory surgery centers (ASCs).

DESIGN

Our study aimed to explore the feasibility and discharge outcomes for MIHs for endometrial cancer in an ASC setting by using same-day discharge data.

SETTING

The prevalence of MIH for endometrial cancer between 2016 and 2019 was estimated from the Nationwide Ambulatory Surgery Sample.

PATIENTS

Patients who underwent MIHs for endometrial cancer at an ASC were included.

INTERVENTIONS

N/A MEASUREMENTS MAIN RESULTS: Weighted estimates of prevalence and association between discharge status and sociodemographic factors were explored. Same-day discharge was defined as discharge on the day of surgery, and delayed discharge was defined as discharge after the day of surgery. An estimated 95 041 MIHs for endometrial cancer were performed at ASCs between 2016 and 2019. Notably, 91.9% (n = 87 372) resulted in same-day discharge, 1.2% (n = 1121) had delayed discharge, and 6.9% (n = 6548) had missing discharge information; 78.7% procedures (n = 68 812) were performed at public hospitals. The proportion of delayed discharges were lower in private, not-for profit ASCs (0.8%, p = .03) than public hospitals. Patients who had delayed discharges on average were older (69.7 vs 62.4 years, p <.001), more likely to have comorbid conditions including diabetes (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.25-1.75) and overweight or obese body mass indices (aOR 1.18, 95% CI 1.01-1.39), and more likely to have public insurance (aOR 1.78, 95% CI 1.40-2.25).

CONCLUSION

MIHs for endometrial cancer are feasible in an ASC. Optimal candidates for receipt of MIHs for endometrial cancer at an ASC are patients who are younger and have less comorbidities, lower body mass index, and private insurance.

Can robotic-assisted surgery support enhanced recovery programs?

Enhanced recovery after surgery (ERAS) protocols comprise a multimodal approach to optimize patient outcome and recovery. ERAS guidelines recommend minimally invasive surgery (MIS) when possible. Key components in MIS include preoperative patient education and optimization; multimodal and narcotic-sparing analgesia; prophylactic measures regarding nausea, infection, and venous thrombosis; maintenance of euvolemia; and promotion of the early activity. ERAS protocols in MIS improve outcome mainly in terms of reduced length of stay and subsequently reduced cost. In addition, ERAS protocols in MIS reduce postoperative pain and nausea, increase patient satisfaction, and might reduce the rate of postoperative complications. Robotic surgery supports ERAS through facilitating MIS in complex procedures where laparotomy is an alternative approach.

Less is more: clinical utility of postoperative laboratory testing following minimally invasive hysterectomy for endometrial cancer

BACKGROUND

With the increasing rates of same-day discharge following minimally invasive surgery for endometrial cancer, the need for and value of routine postoperative testing is unclear.

OBJECTIVE

This study aimed to determine whether routine postoperative laboratory testing following minimally invasive hysterectomy for endometrial cancer leads to clinically significant changes in postoperative care.

STUDY DESIGN

This was a single-institution retrospective cohort study of patients undergoing minimally invasive hysterectomy for endometrial cancer by a gynecologic oncologist between June 2014 and June 2017. Patient demographics, preoperative comorbidities, operative and postoperative data, and pathologic findings were manually extracted from the patients' medical records. The financial burden of laboratory testing was computed using hospital-level cost data.

RESULTS

Of the 649 women included in the analysis, most (91.4%) were White, with a mean age of 61 years, and mean body mass index of 38.0 kg/m². The most common comorbidities were diabetes mellitus (31.9%, n=207), chronic pulmonary disease (7.9%, n=51), and congestive heart failure (3.2%, n=21). Median operative time was 151 minutes (range, 61-278), and median estimated blood loss was 100 mL (range, 10-1500). Most patients (68.6%, n=445) underwent lymphadenectomy. All patients had postoperative laboratory tests ordered: 100% complete blood count, 99.7% chemistry, 62.9% magnesium, 46.8% phosphate, 37.4% calcium, and 1.2% liver function tests. Twenty-six patients (4.0%) had a change in management owing to postoperative laboratory test results. Of these 26 women, 88% experienced a change in clinical status that would have otherwise prompted testing. Only 3 (0.5% of entire cohort) were asymptomatic: 1 received a blood transfusion for asymptomatic anemia, and the other 2, who did not carry a diagnosis of diabetes mellitus, had interventions for hyperglycemia. On univariable analysis, peripheral and cerebrovascular disease, diabetes mellitus with end-organ damage, and a Charlson Comorbidity Index of ≥3 were associated with increased odds of change in management; these were not significant on multivariable analysis. Routine postoperative laboratory evaluation in this cohort increased hospital costs by $292,000.

CONCLUSION

Routine postoperative laboratory tests are unlikely to lead to significant changes in management for women undergoing minimally invasive hysterectomy for endometrial cancer, and may increase cost without providing a discernible clinical benefit. In the setting of strict postoperative guidelines, laboratory tests should be ordered when clinically indicated rather than as part of routine postoperative management for women undergoing minimally invasive hysterectomy for endometrial cancer.

Improved Rates of Same-day Discharge in Patients Undergoing Surgery for Endometrial Cancer Following the COVID-19 Pandemic

STUDY OBJECTIVE

To determine the effect of the coronavirus disease 2019 (COVID-19) pandemic on the rate of same-day discharge (SDD) after minimally invasive surgery for endometrial cancer.

DESIGN

Retrospective cohort.

SETTING

Teaching hospital.

PATIENTS

A total of 166 patients underwent a minimally invasive surgery procedure for the indication of endometrial cancer at a large academic institution from September 1, 2019, to October 1, 2020-80 patients before the implementation of the COVID-19 restrictions and 86 patients after.

INTERVENTIONS

COVID-19 pandemic with visitor restrictions and hospital policy changes placed on March 17, 2020.

MEASUREMENTS AND MAIN RESULTS

SDD rate was increased by 18% after the start of the COVID-19 pandemic (40% vs 58%, p = .02). There were no differences between the 2 groups with regard to operative time (p = .07), estimated blood loss (p = .21), uterine weight (p = .12), age (p = .06), body mass index (p = .42), or surgery start time (p = .15). In a multivariable logistic regression model, subjects in the COVID-19 group had 3.08 times (95% confidence interval, 1.40-6.74; p = .01) higher odds of SDD than those in the pre-COVID-19 group. There was no difference in 30-day readmission rates (7.5% vs 5.8%, p = .66).

CONCLUSION

There was a significant increase in the SDD of patients with endometrial cancer since the start of the COVID-19 pandemic. The pandemic has strained hospital resources and motivated patients and physicians to avoid hospitalization. This shows that with proper motivation, an increase in SDD rates is possible without an increase in complications or rehospitalization.

Applications and Safety of Sentinel Lymph Node Biopsy in Endometrial Cancer

Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.

Same-day hospital discharge after minimally invasive hysterectomy in a gynecologic oncology practice: Feasibility, safety, predictors of admission and adverse outcomes

STUDY OBJECTIVES

1) Determine the feasibility and safety of same-day hospital discharge (SDHD) after minimally invasive hysterectomy (MIH) in a gynecologic oncology practice, 2) Detail predictors of immediate post-operative hospital admission and multiple 30-day adverse outcomes.

DESIGN

Retrospective cohort study.

SETTING

University of Pittsburgh Medical Center Magee-Womens Hospital.

PATIENTS

MIH by a gynecologic oncologist between January 2017-July 2019.

INTERVENTIONS

Clinicopathologic, operative and medical characteristics, and 30-day post-operative complications, emergency department (ED) encounters and hospital readmissions were extracted. Admitted and SDHD patients were compared using descriptive, Chi-square, Fisher's Exact, t-test and logistic regression analyses. Univariate and multivariable analyses (MVA) revealed predictors of post-operative hospital admission, 30-day readmission and a 30-day composite adverse event variable (all-reported post-operative complications, ED encounter and/or readmission).

MEASUREMENTS AND MAIN RESULTS

1124 patients were identified, of which 77.3% had cancer or precancer. 775 (69.0%) patients underwent SDHD. On MVA, predictors of post-operative admission included older age, distance from hospital, longer procedure length, operative complications, start time after 2PM, radical hysterectomy, mini-laparotomy, adhesiolysis, cardiac disease, cerebrovascular disease, venous thromboembolism, diabetes and neurologic disorders (p<.05). 30-day adverse outcomes were rare (complication 8.7% NSQIP/11.9% all-reported; ED encounter 5.0%; readmission 3.6%). SDHD patients had fewer all-reported complications (10.3% vs 15.5%, p=.01), no difference in ED encounters (4.6% vs 5.7%, p=.44) and fewer observed readmissions (2.8% vs 5.2%, p=.05). Predictors of readmission were identified on univariate; MVA was not feasible given the low number of events. Longer procedure length, cardiac and obstructive pulmonary disease were predictors of the composite adverse event variable (p<.05).

CONCLUSION

SDHD is feasible and safe after MIH within a representative gynecologic oncology practice. Clinicopathologic, medical and surgical predictors of multiple adverse outcomes were comprehensively described. By identifying patients at high risk of post-operative adverse events, we can direct SDHD selection in the absence of standardized institutional and/or national consensus guidelines and identify patients for prehabilitation and increased perioperative support.

Historical and Forecasted Changes in Utilization of Same-Day Discharge Following Minimally Invasive Hysterectomy

STUDY OBJECTIVES

To describe changes in length of stay and same-day discharges (SDD) following minimally invasive hysterectomy (MIH) over the last decade and forecast anticipated utilization over the subsequent decade.

DESIGN

Cross-sectional analysis SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

PATIENTS

All benign MIH excluding joint cases with concomitant non-gynecologic surgery in the 2011-2019 NSQIP datasets, identified by current procedural terminology code.

INTERVENTIONS

A descriptive analysis of changes in the estimated length of stay and utilization of SDD from 2011-2019. Multivariable negative binomial regression assessed for individual-level risk factors for prolonged hospital stay and autoregressive linear forecasting estimated the growth of SDD through 2029.

MEASUREMENTS AND MAIN RESULTS

239,220 MIH were identified. Over the 9-year period, SDD increased by 10.7% across all MIH. However, in 2019, SDD represented only 29.8% of total MIH discharges and utilization varied by surgical approach (laparoscopic hysterectomy: 35.4%; vaginal hysterectomy: 18.6%; laparoscopic-assisted vaginal hysterectomy: 19.6%) as well as a surgical indication of pelvic organ prolapse (32.7% without and 13.9% with prolapse). Multivariable models controlling for patient characteristics showed independent associations of route and indication for MIH and length of stay (adjusted relative rate 1.30, 95% CI 1.29,1.32 for vaginal hysterectomy and aRR 1.12, 95% CI 1.11, 1.14 for prolapse), however, these individual-level factors provided limited information explaining variation in the length of stay (model pseudo-R2 0.054). Forecasting models suggest that utilization of SDD will grow to 48.5% (95% CI 38.7-58.4) by the end of 2029.

CONCLUSION

While the estimated length of stay is decreasing among MIH over time, the utilization of SDD remained low in 2019, and was not explained by patient factors. If current trends hold, SDD utilization is not forecast to exceed 50% through 2029. Additional efforts focused on the provider and institution level are needed to encourage SDD as the standard of care for MIH.

Trends in Same-Day Discharge Rate After Minimally Invasive Sacrocolpopexy and Propensity Score-Matched Analysis of Postoperative Complication Rates Using the National Surgical Quality Improvement Program Database

OBJECTIVE

The primary aim of this study was to review trends in the same-day discharge (SDD) rate after minimally invasive sacrocolpopexy (MISCP). The secondary aim was to compare the composite 30-day postoperative complication rates between propensity score-matched SDD and admitted cohorts.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2019. Patients who underwent MISCP were identified by Current Procedural Terminology codes. Concurrent hysterectomy, anterior or posterior repairs, rectopexy, and midurethral sling were also identified. Multivariable logistic regression and propensity score matching were performed.

RESULTS

A total of 12,762 MISCP patients were captured: 3,968 underwent MISCP only, 4,065 underwent MISCP with total laparoscopic hysterectomy, 734 underwent MISCP with laparoscopically assisted vaginal hysterectomy, and 3,995 underwent MISCP with laparoscopic supracervical hysterectomy. Overall, the SDD rate was 16.3%, with an increase from 12.3% in 2015 to 23.1% in 2019. Multivariable logistic regression showed that admitted patients were more likely to be older, to be of Black race, have an American Society of Anesthesiologists classification of 3 or 4, have hypertension requiring medication, have longer operative time, and have undergone concurrent anterior or posterior repair, rectopexy, or sling. After propensity score matching, the composite postoperative complication rates were similar between the 2 cohorts (5.7% vs 6.4%, P = 0.818). However, superficial surgical site infection was more likely in the SDD cohort (adjusted odds ratio, 2.3; P < 0.001) and blood transfusion in the admitted cohort (adjusted odds ratio, 11.9; P = 0.0.34).

CONCLUSIONS

The rate of SDD after MISCP seems to be increasing. Composite postoperative complication rates are similar between SDD and admitted cohorts.

Enhanced Recovery after Surgery (ERAS) Protocol for Early Discharge within 12 Hours after Robotic Radical Hysterectomy

To evaluate safety of quick discharge after robotic radical hysterectomy (RRH) in a tertiary hospital which has the enhanced recovery after surgery (ERAS) protocol. Among 94 consecutive cervical cancer patients who had undergone RRH, operative outcomes and the rate of unexpected visit after surgery were analyzed retrospectively. Patients were categorized as a surgery-to-discharge time of ≤12 h (early discharge [ED]) or >12 h (late discharge [LD]). About 77% (n = 72) of analyzed 94 patients discharged within 12 h after RRH. The ED group had significant correlation with shorter duration for urinary catheter required, less operative blood loss, and less voiding difficulty after long-term follow up compared to the LD group. There was no difference of perioperative complications and unexpected visit between the two groups. Performing nerve sparing (NS) RRH was only independent predictor for ED (p = 0.043, hazard ratio for LD = 0.22, confidence interval = 0.05–0.95). In conclusion, the ED within 12 h after RRH was safe in the setting of ERAS protocol. The NS-RRH could avoid the delay of genitourinary function recovery after surgery which caused LD. It can become the reasonable clinical pathway to discharge early patients who undergo NS-RRH with ERAS protocol.

Predictors of same-day discharge after minimally invasive hysterectomy for benign indications

OBJECTIVE

To identify predictors of same-day discharge after benign minimally invasive hysterectomy.

METHODS

In this retrospective cohort study, we identified women (n = 1084) undergoing benign minimally invasive hysterectomy from 2009 to 2016. Multivariate logistic regression was used to examine demographic, operative, and surgeon factors associated with discharge on postoperative day 0.

RESULTS

In our study population, 238 women (22%) were discharged on the same day. Robotic hysterectomy (risk ratio [RR] 2.24; 95% confidence interval [CI] 1.13-4.44), shorter operative time (lowest quartile; RR 5.28; 95% CI 2.66-10.46), and minimal blood loss (lowest quartile; RR 3.01; 95% CI 1.68-6.23) were associated with higher same-day discharge likelihood whereas later procedure start time (2-5 pm; RR 0.38; 95% CI 0.17-0.85) and postoperative complications (RR 0.19; 95% CI 0.06-0.55) significantly decreased its likelihood. The strongest predictor was surgeon's number of years in practice, with recently graduated surgeons more likely to discharge their patients on the same day (RR 3.15; 95% CI 2.09-4.77).

CONCLUSION

Same-day discharge after minimally invasive hysterectomy is determined by several patient, operative, and surgeon factors that can be incorporated into an implementation plan to promote earlier discharge. Most especially, scheduling patients based on perceived case complexity and targeted surgeon education can qualify a larger cohort for same-day discharge.

Outpatient Hysterectomy versus Inpatient Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

The aim was to investigate whether outpatient hysterectomy (OH) has benefits when compared with inpatient hysterectomy (IH) regarding postoperative complications, readmissions, operative outcomes, cost, and patient quality of life.

DATA SOURCES

A systematic search for studies comparing OH with IH was conducted through PubMed, SAGE, and Scopus from January 2010 to March 2020, without limitations regarding language and study design.

METHODS OF STUDY SELECTION

Studies reporting on the differences between same-day discharge and overnight stay after hysterectomy were included. The study outcomes were overall complication rate, type of complication, readmission after discharge, surgery duration, estimated blood loss, payer savings, hospital savings, and health-related quality of life (HrQoL). Median and range are used to describe non-normal data, while mean ± SD and confidence interval are used to descibe data with normal distribution. A meta-analysis with sensitivity analysis and subgroup analyses was performed.

TABULATION, INTEGRATION, AND RESULTS

Eight studies published between 2011 and 2019 with 104,466 patients who underwent hysterectomy were included in this systematic review and meta-analysis. All included studies except 1 were found to have a high risk of bias. OH in comparison with IH had a lower overall complication rate (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.60-0.82) and lower rates of wound infection (OR 0.60; 95% CI, 0.43-0.84), urinary tract infection (OR 0.64; 95% CI, 0.52-0.78), need for transfusion (OR 0.36; 95% CI, 0.22-0.59), sepsis (OR 0.33; 95% CI, 0.17-0.64), uncontrolled pain (OR 0.79; 95% CI, 0.66-0.95), and bleeding requiring medical attention (OR 0.82; 95% CI, 0.73-0.94). In addition, patients who underwent OH had a lower readmission rate (OR 0.81; 95% CI, 0.75-0.87), surgery duration (standardized mean difference -0.35; 95% CI, -0.61 to -0.08), and estimated blood loss (standardized mean difference -0.63; 95% CI, -0.93 to -0.33) than those who underwent IH. A qualitative analysis found that OH had a poorer patient HrQoL and a lower cost for the hospital as well as the payer.

CONCLUSION

OHs present fewer complications and have a lower readmission rate and estimated blood loss as well as a shorter surgery duration than IHs. OHs also have a cost benefit in comparison with IHs. But patients seem to have a worse HrQoL in the first postoperative week after OH. The high risk of bias of the included studies indicates that well-designed clinical trials and standardization of surgical complication reporting are essential to better address this issue.

Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway

STUDY OBJECTIVE

Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m² undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP.

DESIGN

A retrospective cohort study.

SETTING

An academic teaching hospital.

PATIENTS

A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m²) undergoing robotic hysterectomy.

INTERVENTIONS

The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls.

MEASUREMENTS AND MAIN RESULTS

Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room).

CONCLUSION

The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.

The effect of frailty on postoperative readmissions, morbidity, and mortality in endometrial cancer surgery

OBJECTIVES

To determine the impact of frailty on postoperative readmission, morbidity, and mortality among patients undergoing surgery for endometrial cancer.

METHODS

Patients with endometrial cancer undergoing hysterectomy between 2010 and 2014 were identified using the Nationwide Readmissions Database. Frailty was classified using criteria outlined by the Johns Hopkins Adjusted Clinical Groups Frailty Diagnoses Indicators. Primary outcomes were divided by index surgical admission (intensive level of care, mortality, non-routine discharge), 30-days (readmission and mortality), and 90-days (readmission and mortality) after discharge. Multivariable log linear regression models were fit to analyze the effect of frailty on these outcomes, adjusting for patient, hospital, and clinical factors.

RESULTS

From 2010 to 2014, there were 144,809 surgical endometrial cancer cases with a 1.8% frailty rate. Frailty was associated with an increased risk of intensive level of care (aRR = 3.61, 95% CI: 2.95, 4.42), non-routine discharge (aRR = 1.59, 95% CI: 1.51, 1.68), and inpatient mortality (aRR = 2.05, 95% CI: 1.68, 2.51) during index admission. Frail patients were more likely to be readmitted within 30 days (RR 1.33, 95% CI 1.22-1.47) and 90-days (RR 1.21, 95% CI 1.12, 1.32), and were at increased risk of mortality during their 30-day readmission (aRR = 1.75, 95% CI: 1.28-2.39). Frailty was not associated with 90-day mortality. Hospitalization costs for frail patients were significantly higher than for non-frail patients during index admission and readmissions within 30 and 90 days (p < 0.05 for all).

CONCLUSIONS

Frailty affects postoperative outcomes in endometrial cancer patients and is associated with an increased rate of readmission and 30-day mortality among those who are readmitted. Gynecologic cancer providers should screen for frailty and consider outcomes in frail patients when counseling them for surgery.